Provider First Line Business Practice Location Address:
20202 W INDIANA LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDICAL LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99022-8747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-993-1134
Provider Business Practice Location Address Fax Number:
509-244-9547
Provider Enumeration Date:
01/04/2013